Basic Information
| Provider Information | |||||||||
| NPI: | 1225659345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KWAK | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PEDIATRIC RESIDENCY PROGRAM | ||||||||
| Address2: | 160 E. ERIE AVENUE | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154275000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 160 E ERIE AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191341011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154275000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2020 | ||||||||
| LastUpdateDate: | 06/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | MT221095 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.